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DEC-19-1996 15~59 FROM CUMMINGS TRANSFER TO 15032746524 P.03
<br />D E~2%1] Oo ~1~: J,3 E~S69~a e.~g~ c,u r- n x S~Lea[ HOC9IN6 c~ . ,~603/~OS ;
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<br />L1t~lc oi Lf~~t~4Ri5 j- '
<br />~' sf C~•'a~-+Se ~° ~'~` PoRc~l !'criod l+' 000 000
<br />'~},i~ ~rtdgra~tr~rnfiA~4c~ F~om12~1~96 T~ 12/1/97 ~ ~--_,.. L - ___ ~
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<br />Sci+eri~.tEd ac.ns or bcaior.s arc w b~ i~,~lil~od or~. ~. alrn~l-r./ :h.ec " `"
<br />'I~C fc+ft4a~ng industoc~s, Qc~Jue~o~s, ~cteacions at specifit p~o~s'bN~ ~l~v~ to the ~bova ooYCte~e Ap,~~B~ra
<br />llm~tc er~ s4~~~.te d~~KC.iblv•, ~+YPlic~bkt ue ro be s+oaed .lFcr s~e seRMd c~~~g~- ~~TSCh .v~~l~e4r+n,.l ~g~ra !i' ~
<br />spa~e is ir~,s~dfi~ ik,zt.) :
<br />~chides: '
<br />{ X) Ft~.~.rniTras &C)pararion~ ~ x ) Incid~ on H~dl M+~~pt~+cc~c~ .
<br />( X) CarL,-.:et~1 Z.~~Mi~ry, Orel 6e~Ir;~r~n ( X ) C~llap K.r.«ed
<br />~ X ~ Yssd','~~idErr Co~iu~ct~,rs : :
<br />( g ) P~9uc~+t+lctv+dO~ractoas - ( X ~ v-~d~t8~o'v~dN~rd < :
<br />( g ) Er~~Ad ~t'~a prc~ity Dam•~e, Tnol. f ) C~a~a I<<~•~s i~$al liabilic~' i
<br />C,:o~+'.~•:S•d ~~`~ S ~ .
<br />( x ) I~r~;,,1 I~i~~~, F~. C Deter~xl ( x 1 4~ned A~canobl4:s . , ` ~
<br />~.~,ti~mS ( }( ) IaToo-o~+s~ea Aucprt~t~les . ; i
<br />~ X ) BroaA I'~~tn T~~billcy Endoc~rm~ac ( X )~-t~Ted pv~~«.R,~~t~ ,
<br />~ X ) F!K t.~~,1 T~ph;U~y ( J ; ; , , ~
<br />( X } wdt}~ir~ft URh+1-ry ~
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<br />E~clud~= ~ ; , . _ ,
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<br />~~~~'' $500.00 - Property Damage ~ ~ ;
<br />~alasaa~f~ik~oucoc-e)oE~_~ Properit,y Damage ~..~ ~
<br />Adedat~hia ~x~-#~~ .epetiat w ~~~
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<br />~„c,~,ik ~1~+p`•fcs Ptr Claim ( ) Yar Oect~snce ( X )• . ~
<br />American Auto InsuYance Co.
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<br />. I~r~t ~~~ ; ~
<br />P. CLBox 29018 ' '
<br />A,dc~reu: , .~~--- ---- --,- ~- ~ - - ;
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<br />Portland, OR i „ ,"~ _ •
<br />.,.._.~.. -. ._ .~~ __~., ,
<br />Timothy J. Nielsen _(cype at ph~t nsme~ ~UC~ebp d~lA~e undor pe~~ty ~~p*%~~n y~d;~ e~'~
<br />~, . _......_..... _... . . ..
<br />taws o~c~x S~a;e QE _. ~ t~at I~avE the Qt orie~- !~ h''d the abo+t~•na~~d i~~ut~+c,e een ~~ny. ' .
<br />~~. ,...-. _...-
<br />7his tndur.~aKne,-c *nd by mr execudvn he~co~ d9 ~o b« " a+r'+~i'a . . .
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<br />Sip~xu~e a n. enq~d"~ ~
<br />(Oripie~i it~ ~YI No 6rs(ewfle ,
<br />s~tnaane or (ri~tts4d si~t~~~+ x~~+e~d~
<br />Portland, OR o,~ ~„~..,:~..19;~,.,_:.:_,~:.._ -' , ~
<br />FaceCU6N~ A~ , .. -.,---.-•- .-~...~r . t. ~-- • -- --- - ~. __--.. ; , ; ~' ; .
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<br />e No.: ( SD3 ) 79 9 ~ .
<br />Phon ; fl ';„....~'~~ _~- ;;{;f;,: .
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<br />~ DEG-11-1995 13~11 1399732f 96i ~ P•~
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